AHTR (acute hemolytic transfusion reaction)

Fever
Chills, rigors
Pain: lower back, flanks, chest, along infusion vein
Dark urine
Oliguria
Hypotension
DIC
Renal failure

Laboratory findings:
Hemoglobinemia
Hemoglobinuria
Positive Direct Antiglobulin Test
Indirect hyperbilirubinemia
Low serum haptoglobin

Management
STOP TRANSFUSION
Remove blood unit, maintain IV access, change IV line
Supportive approaches
Monitor and maintain vital signs
Give normal saline Intravenous crystalloids (NaCl 0,9% 1020 mL/kg)
Maintain renal perfusion:
Furosemide 12 mg/kg/dose (IV) maintain diuresis > 1 mL/kg/hour
Dopamine (15 g/kg/min) for hypotension
FFP, thrombocyte, cryoprecipitate for DIC with bleeding

Workup
Check patient identity and label
Check blood and urine:
Direct antiglobulin test (DAT)
Repeat crossmatch & blood group typing
Urinalysis
Bilirubin serum, haptoglobin serum
Renal status: diuresis, BUN, creatinine
Blood culture
Send remaining blood to PMI
Make report (medical record & PMI)
 FTNR (Febrile nonhemolytic transfusion reaction)
Rise in patient temperature >1C (associated with transfusion without other etiologic factors)
Caused by alloantibodies directed against HLA antigens
Occur during transfusion or within 6 hours after transfusion
Need to evaluate for AHTR and infection
RBC transfusion: 0.5-5%
Platelet transfusion: 1-38%

Risk factors:
Recurrent transfusion
History of FNHTR
Hematology/oncology patient
Older age (FNHTR due to platelet transfusion in children 5-20%, in adult 18-38%)

Mechanism:
Activation of recipient leukocytes and endothelial cells by transfused donor leukocytes or plasma
constituents, or by the passive transfer of cytokines that accumulated in the unit during storage

Clinical Features
Fever after 30-90 min
+ Rigors
+ Headache
No Hypotension
No Bronchospasm
No flank pain
No haemoglobinaemia
No Haemoglobinuria

Management:
STOP TRANSFUSION
Use of Antipyreticsresponds to Tylenol
Use of Corticosteroids for severe reactions
Use of Narcotics for shaking chills
Future considerations
May prevent reaction with leukocyte filter
Use single donor platelets
Use fresh platelets
Washed RBCs or platelets

If Temp < 40 + Stable patient:

Stop transfusion
Antipyretics ( No rule of Anti-histamines )
Check the bag and cross match
Exclude red urine or red plasma
Resume transfusion at a slower rate
If recurrent: Leucodepleted transfusion in the future
If Temp 40 or more + Unstable patient:
Stop transfusion
Manage as possible acute haemolytic reaction till lab. Confirmation or exclusion.

Prevention/ Recurrence of FNHTRs:

pre-transfusion administration of antidotes
documented BTR, warrants pre-transfusion medications 30 minutes before blood
transfusion
use leukocyte-depleted blood
removal of buffy coat
sedimentation
red cell washing
use of micro-aggregate filtration (leukoreduction)

Clinical presentation Treatment Prevention

Fever ( >1C) Acetaminophen (orally, 1015 Acetaminophen (10-15 mg/kg/dose)

Chills, rigors mg/kg/dose) 60 min before transfusion
Nausea Supportive care as needed Use leukocyte-reduced or washed blood product
Vomit
Headache
ALLERGIC TRANSFUSION REACTION
due to plasma proteins or blood preservative/ anticoagulant
Reactors: Patient antibodies of IgE type
Response:
Mast cell degranulation
+ Complement Activation
+ Cytokines

Clinical Features
Mild / Skin-restricted:
Pruritus, Uerticaria, No fever or Hypotension
Severe / Systemic ( Anaphylaxis):
As above plus:
Fever
Hypotension
Bronchospasm, Angioedema

Management
Mild / Skin-restricted :
Stop transfusion temporary
Anti-histamines
Resume Transfusion

Severe / Systemic ( Anaphylaxis):

Stop transfusion
Anti-histamines ( H1+H2 blockers)
Epinephrine: 1 ml of 1/1000 IM
Hydrocortisone 100 mg IV
Cardio-pulmonary support
 Transfusion Related Acute Lung Injury
TRALI

Clinical syndrome similar to ARDS

Occurs 1-6 hours after receiving plasma-containing blood products
Caused by WBC antibodies present in donor blood that result in pulmonary leukostasis
Treatment is supportive
High mortality

Clinical Features
Fever, chills
Acute Respiratory Distress
Normal CVP (Central Venous Pressure)
CXR: Pulmonary Infiltrate
Management
Cardio-Pulmonary Support
Steroids
Diuretics of No value
Mortality : high

TACO

Acute cardiogenic pulmonary edema

In rapidly transfused, non-bleeding (euovolemic) patients
More in infants, elderly or cardiac patients

Signs & Symptoms

Cough
Dyspnea
Pulmonary congestion
Headache
Hypertension
Tachycardia
Distended neck veins
No Fever (DD from TRALI, FNHTR)
No red urine or plasma and Negative Coombs (DD from Acute haemolytic reaction)

Management
Diuretics
Consider haemodialysis
Supportive

Prevention
Never exceed 2-3 ml/kg/hourunless ongoing bleeding
Pre-medicate with diuretics in cardiac or severely anemic patients